Introduction Bilateral diffuse uveal melanocytic proliferation (BDUMP) is a potentially devastating rare paraneoplastic syndrome often associated with severe vision loss occurring in patients with underlying carcinoma. In approximately 50% of cases this may be the first sign of an underlying primary malignancy. First described in 1966 there are currently less then 100 cases described in the literature. Treatment of this condition includes treatment of the primary malignancy and plasmapheresis. We describe what we believe to be the first case reported in a lung transplant recipient. Case Report A 72 year old woman status post bilateral lung transplant for COPD was referred to ophthalmology due to increased vision loss for four months, one month prior to presentation she had undergone a left YAG capsulotomy. Maintenance immunosuppression included tacrolimus, mycophenolate mofetil, and prednisone. Fundus exam was remarkable for bilateral retinal pigment epithelium mottling and leopard spot fundus. Exam on the left showed edema. BDUMP was diagnosed, she was admitted to the hospital for plasmapheresis and an extensive evaluation for underlying malignancy. Remarkable laboratory studies showed a new acute kidney injury in the setting of chronic kidney disease with nephrotic range proteinuria. All tumor markers, ANA, ANCA, SPEP, and PLA2R were negative. CT of the head, chest, abdomen, and pelvis were unrevealing, PET scan showed a hypermetabolic breast nodule which was biopsied. The biopsy was consistent with ductal carcinoma in situ, and her mycophenolate was stopped. She completed 14 sessions of plasmapheresis and had improvement in her vision. Summary BDUMP, a rare condition which left untreated can lead to rapid vision loss, is associated with carcinomas of the cervix, uterus, ovary, lung, kidney, pancreas, breast, gastrointestinal tract, and Hodgkin lymphoma. While the exact pathogenesis for BDUMP has not yet been described it has been shown that these patients have a factor in the IgG fraction of serum that selectively causes melanocyte proliferation and thus plasmapheresis is an effective treatment. Patients that are immune suppressed are at an elevated risk for cancer, therefore it's highly important to keep up with health maintenance examinations in this population. Visual changes after transplant are also common, and a complete ophthalmologic examination should be completed with new onset of symptoms.